Mixed Reaction to CMS' Release of Nursing Home Quality Data

by Joanna Shoffner with Kathleen M. Wilson

WASHINGTON, DC--Calling the recent release of nursing home quality data "important and wonderful news for the nation's elderly," Secretary of Health and Human Services Tommy Thompson released the first set of results from the six-state pilot project, the Nursing Home Quality Initiative. Designed to provide Medicare beneficiaries with better information to compare nursing homes, the Centers for Medicare and Medicaid Services published the quality data ("performance measures") received from nursing homes in Colorado, Florida, Maryland, Ohio, Rhode Island, and Washington (for additional perspectives on the initiative, see "Making (Up) the Grade: What You Need to Know About Nursing Home 'Report Cards'" in this issue).

The data used in the initiative are derived from the Minimum Data Set (MDS), the resident assessment information that facilities are required to submit to CMS at specific intervals (also see "Cultural Change Key to Nursing Home Quality Initiative" in the March 2002 issue of Caring). The MDS data were converted into the nine quality measures that are now being reported publicly (data released in April were calculated from MDS assessments performed between October and December 2001).

Measures selected for the initiative had to meet four criteria. They had to be important to consumers, accurate (reliable, valid, and risk-adjusted), comparable, and influenced by staff providing a high quality of care.

Some of the data--on pressure ulcers, decline in activities of daily living, and pain management--appeared in advertisements in 30 newspapers across the six states. Information on the remaining six indicators is posted at www.medicare.gov. Additional measures have not yet been decided upon, but could appear when the program is rolled out to all nursing homes later this year.

"By generating and publishing quality data, we are both helping consumers to make decisions that best meet their needs and creating market incentives for nursing homes to further improve quality," said Secretary Thompson at a recent briefing.

Changing Measures

The nine measures reported in the pilot were recommended by the National Quality Forum (NQF), an independent standard-setting organization (see box at right). Originally, the pilot consisted of 11 measures--seven chronic and four post-acute measures.

During the course of the project, two measures--indicators for anti-psychotic drug use and re-hospitalizations--were dropped, largely because of risk-adjustment and other issues raised by stakeholder groups. For example, the measure for anti-psychotic drug use was dropped because its inclusion could have inadvertently encouraged the use of inappropriate medications--such as anti-epileptic or anti-anxiety drugs--that potentially cause more adverse side effects.

CMS officials asserted that the quality data are not "report cards," but rather information designed to allow consumers to make "apples-to-apples" comparisons of their local nursing homes.

Provider Response

Although association leaders see the value of offering consumers more information on the quality of care provided in nursing facilities, they worry that the data alone do not reveal the entire picture of what is going on in a facility. They are also concerned that the data do not take into account the distinct patient populations in nursing homes (see box, AMDA's Response: An Excerpt, below).

"There is still much to be learned about measuring quality and using that information to improve nursing home services," said Larry Minnix, Jr., DMin, President and Chief Executive Officer of the American Association of Housing and Services for the Aging. Dr. Minnix noted that care quality presents an imminent challenge to nursing homes, as new care options such as assisted living emerge for seniors.

Mary Ousley, RN, Chair of the American Health Care Association, said the data release is "bold, timely, and historic." She emphasized that the long-term care community must continue to work toward using "actual outcomes" to determine care quality.

However, Susan Levy, MD, CMD, a Multi-Facility Medical Director in Baltimore, MD, said, "my concern remains whether this type of data can really be used to compare facilities. Much of it is appropriate for internal benchmarks or to compare improvement over time, but it may not be the best way to make facility-to-facility comparisons.

"I know of a facility that scored high on pain management [higher percentage than state average], but I also know that in the past, this facility has taken a lot of post-operative orthopedic patients," she said, which probably accounts for its high score in this measure.

Dr. Levy also expressed concern that many facilities may not have received sufficient information about the project or about how the indicators would be used. Although CMS mailed preview materials to nursing home administrators, the materials may not have found their way to other key facility staff.

Consumer Reaction

Consumer groups expressed support for the intent of the project--to provide better information to make choices about nursing homes--but remain concerned about how useful it will really be for families. For example, Liz Taylor of Bainbridge Island, WA, owner and founder of Aging Deliberately, a private enterprise that teaches families how to search for long-term care options, expressed concern about the complexity of some of the quality measures and the difficulty of navigating the CMS Web site.

Ms. Taylor, who acknowledged that public reporting is long overdue, also pinpointed long-term care jargon as a potential barrier. For example, she noted that "most families do not know what 'post-acute' care is. It is a relatively small part of the nursing home market, usually selected in crisis, used short term, and governed by Medicare. It is too complicated to be included in the project." Moreover, although the quality data are important, "they will be irrelevant if they punish high-quality providers who take care of heavy-care residents, or if the data are not easy for consumers to use and understand."

National Citizens Coalition for Nursing Home Reform Executive Director Donna Lenhoff, who is also a member of Caring's Editorial Board, observed that although quality data are important, they are only one "aid" families could use in selecting a facility. "No one should choose a nursing home without visiting it and observing firsthand the quality of care--whether residents are responded to quickly when they call for help, and whether staff treat residents with respect and kindness," she said.

Dr. Levy agreed, noting that "the best indicators of the quality of care are how patients and their families perceive the facility and their willingness to recommend the facility. When it comes to providing long-term care, most people, if they are involved at all, can make some determinations as to whether their loved one is getting the care that they need."

Next Steps

The NQF will revisit the measures used in this six-state pilot and select the ones that will be used in the national rollout in October. Following a period of public comment and review by members of the NQF, a draft of proposed quality measures will be sent to the organization's Board of Directors for endorsement.

Mr. Scully noted that "our first step in this pilot is nursing homes. Next year, we plan to expand our public education efforts to other health care providers."

Joanna Shoffner is AMDA's Health Policy Analyst. Kathleen M. Wilson is AMDA's Former Director of Government Affairs and a Contributing Writer to Caring.

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